ASSISTED LIVING HOME EMPLOYMENT APPLICATION
Disclosure of this information for Employment
by an Assisted Living Home Job Applicant is required by Alaska State Law
This application is for the position of:
Administrator-must be at least 21 years of age.
Supervisor of Care Providers-must be at least 21 years of age for an Assisted Living Home with six
or more residents or three or more employees.
Care Provider must be at least 16 years of age for an Assisted Living Home with six or more
residents or three or more employees. Definition: “Care Provider” means an individual who
provides direct care to, or who does not provide direct care to but has regular contact with,
residents of an Assisted Living Home, including an individual who is employed by or contracts with
the Home, and an individual at least age 16 who is a member of the family of the administrator or
owner of the Home; the term does not include an individual who is a volunteer or employee of a
care-providing entity not affiliated with the Home.
I understand that:
a. within 30 days of employment I must provide to the Licensing Agency the results of a fingerprint
criminal background investigation conducted by the Alaska Department of Public Safety.
the Assisted Living Home will not continue to employ me if my fingerprint criminal background
history reveals information conflicting with my sworn statement concerning conviction of a
felony; a misdemeanor involving drugs or physical or sexual abuse; or a misdemeanor
if I have been convicted of a crime described in 2.b. of this application I may still serve as an
employee of the Assisted Living Home if I truthfully reveal the conviction and provide evidence
satisfactory to the Home and the Licensing Agency that I do not pose a risk to the residents
and will not adversely affect the safety or effective operation of the Home.
if after employment by the Assisted Living Home I am convicted of a crime described in 2.b. of